In
Incident - An event that could have or did cause harm.
Events that could have resulted in harm are also commonly called near misses . Harm may be to people, property, the environment or other.
Hazard - Something with the potential to cause harm
Reporter – The person first on the scene and/or completing this form
Program Manager – Senior Manager responsible for a program or function
HSR – Elected Health and Safety Representative
Please report all incidents, near misses and hazards. Your report is vital to improving
Hazard reporting and management process (for incidents see next page)
Hazard identified
SERIOUS
hazard?
(risk of immediate and/or serious harm to people?)
Yes
No
Reporter
Complete Parts A and E of the
Incident and Hazard Report
Form, send to team leader / manager
Manager and HSR
Complete Parts F to H
(investigation/actions)
Send COMPLETED form to HR within 3 days (Email, fax or mail)
OTHERWISE send
INCOMPLETE form within 3 days, send COMPLETED form once completed
Manager and HSR
Implement corrective actions or monitor implementation if by another party
Human Resources
Enter form data into incident and hazard database
Complete Part I
Reporter
Phone manager to report situation
Manager
Phone WHS Consultant for advice where necessary.
Inform HSR.
Manager
Implement quick-fix prior to final actions where necessary
Document number
Page number
WHS-302.1, Incident and Hazard Report Form
1 of 5
Date
Authorised by
10 December 2012
Director Human Resources

Incident reporting and management process
Incident occurs
Reporter
Assist injured persons, organise first aid and/ or call ‘000’
SERIOUS
INCIDENT? (refer
table at right) – if unsure proceed as
‘Yes’
Yes
No
Reporter
Complete Parts A to D of the
Incident and Hazard Report
Form, send to team leader / manager
Manager and HSR
Complete Parts F to H
(investigation/actions)
Send COMPLETED form to HR within 3 days (Email, fax or mail)
OTHERWISE send
INCOMPLETE form within 3 days, send COMPLETED form once completed
No
Reporter
DO NOT disturb the scene and RESTRICT access to the scene
Phone Program Manager to report the situation
Program Manager
1. Phone WHS Consultant (if not contactable call HR
Manager) for advice on whether the incident must be notified to the WHS regulator in your state/ territory.
2. Inform HSR.
Is the incident notifiable?
Yes
WHS Consultant
1. Assist Program Manager with notification process.
2. Advise HR Manager
Human Resources
Enter form data into incident and hazard database
HR Manager
Ensure activation of
CRITICAL ISSUE process to inform relevant NLT members
The scene cannot
be disturbed until permission is received from the regulator
What is a SERIOUS INCIDENT?
1. SERIOUS INJURIES
* Death of a person
* Hospital inpatient admission
* An electric shock
* Immediate treatment by a
medical practitioner REQUIRED
(even if declined) for:
a) Amputation
b) Head injury
c) Eye injury
d) Burn
e) Separation of skin from
other tissue
f) Spinal injury
g) Loss of bodily function
h) Laceration (cut)
* Medical treatment within 48 hours of
exposure to a chemical
* Occupational diseases and some
infectious diseases
2. DANGEROUS OCCURRENCES
* Spill of a hazardous chemical
* An explosion or fire
* Escape of gas or steam
* Falling items or equipment
* Collapse or partial collapse of any
structure
Program Manager
Commence internal investigation with WHS Consultant and HSR
No
Are there contract reporting requirements?
Yes
Program Manager
Action contract reporting requirements
Document number
Page number
WHS-302.1, Incident and Hazard Report Form
2 of 5
Date
Authorised by
10 December 2012
Director Human Resources

PART A: Reporter to complete for ALL incidents, near misses and hazards
Date of report Time of report
Type of report Incident (including near miss) Hazard
Name
Reporter
(person completing the form for themself or on behalf of another person)
Phone number
Signature
State
Site Name
PART B: Reporter to complete for incidents and near misses ONLY
People affected
(tick applicable)
Staff Volunteers
If other, please specify
Incident date Incident time
Incident location
Witness Name (1)
Witness Name (2)
Phone number
Phone number
Describe what happened?
(Facts not opinions)
Other
Document number
Page number
WHS-302.1, Incident and Hazard Report Form
3 of 5
Date
Authorised by
10 December 2012
Director Human Resources

PART C: Reporter to complete for injury or illness ONLY
Name of injured person
Contact details
Nature of injury or illness. (for example sprain, cut, respiratory distress)
Location of injury (for example left arm, lower back)
Treatment required
(tick applicable)
None
Medical treatment (treatment
by medical practitioner)
First aid ( treatment by first aider only)
Hospital inpatient admission
PART D: Reporter to complete for harm OTHER THAN INJURY/ILLNESS ONLY
Describe the harm
(for example property damage)
PART E: Reporter to complete for hazards ONLY
Describe the hazard
Location of the hazard
Steps taken to make hazard safe?
Thank you for completing this report - Please forward to your manager
Document number
Page number
WHS-302.1, Incident and Hazard Report Form
4 of 5
Date
Authorised by
10 December 2012
Director Human Resources

Manager name
Is this incident notifiable?
(see page 2)
Date and time regulator notified
Date and time funder notified
Date made aware of incident / hazard
Investigation conducted by (list people, including HSR
(Health and Safety
Representative)
Name of WHS Consultant or HR
Manager whom notification was discussed with
WHS regulator reference number
Program Manager name
Date investigated
Incident causes / hazard control comments – attach more if necessary
Corrective action 1
Manager responsible for action
Date
Corrective action 2
Manager responsible for action
Date
Corrective action 3
Manager responsible for action
Date
PART H:
Manager Name
Signature Date
HSR Name
Signature
PART I: Human Resources use ONLY
Received by
Database entry by
Document number
Page number
WHS-302.1, Incident and Hazard Report Form
5 of 5
Date
Date
Date
Date
Authorised by
10 December 2012
Director Human Resources